The Journal of School Nursing2025, Vol. 41(6) 689–701© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405241266237journals.sagepub.com/home/jsn
Abstract
School nurses (SNs) practicing in DC public and public charter schools were surveyed to assess their perceived role and selfreported preparation to provide behavioral health prevention, early identification, and treatment services in schools. A total of 154 SNs completed a questionnaire about their role in the delivery of behavioral health services and supports. SNs reported they are primarily involved in the identification and referral of students to other school behavioral health professionals. Respondents also reported a lack of training in behavioral health and a desire for more information on related programs and services. This study offers recommendations for educating future SNs and highlights how the DC School Health Services Program utilized study findings to build capacity for SNs employed in practice. This study can help tailor educational opportunities for SNs to maximize their role in school behavioral healthcare process flows and ultimately improve outcomes for students and families.
Keywords
school nurse knowledge/perceptions, school nurse education, standards of care, mental health
Youth behavioral1 health has worsened over the last 10 years and disparities by gender, race, ethnicity, and sexual identity and orientation persist (Centers for Disease Control and Prevention [CDC], 2023), with depression, anxiety, and conduct problems reported as some of the most pressing issues for which treatment gaps remain (Ghandour et al., 2019; Whitney & Peterson, 2019). Approximately 5 million U.S. adolescents (ages 12–17 years) had at least one major depressive episode (Substance Abuse and Mental Health Services Administration [SAMHSA], 2022), but over 60% of major depressive episodes in adolescents go untreated (Substance Abuse and Mental Health Services Administration [SAMHSA], 2020). More recent estimates show that 42% of high school students across the U.S. report feeling persistent sadness or hopelessness and 22% have seriously considered suicide (CDC, 2023). In DC, youth behavioral health is a significant concern. For example, the percentage of DC high school students who report feeling sad or hopeless has been increasing: 27.2% in 2017 compared to 36.3% in 2021. Moreover, in 2021, 18.3% of high school students in DC seriously considered attempting suicide (DC, 2021).
The need for behavioral health support for youth has been exacerbated by the COVID-19 pandemic and has fueled federal, state, and local policy actions, along with calls for stronger school-based supports, to combat the negative health and educational outcomes associated with unmet behavioral health needs (Hertz & Barrios, 2021; Office of the Surgeon General, 2021; Samji et al., 2022). Schools are important and effective settings to address youth behavioral health conditions (Hoover & Bostic, 2021). School nurses (SNs), as one vital member of the school community, spend an estimated one-third of their time focused on student behavioral health concerns but are not typically acknowledged or included as part of a school’s coordinated student behavioral health response (Bohnenkamp et al., 2015; Shattuck et al., 2024). Yet, a shortage of evidence exists to determine if nurses are practicing to their full professional scope and what barriers might limit SN’s impact on student behavioral health outcomes (Hoskote et al., 2023).
Despite the prevalence and negative impact of unmet behavioral health issues, not all youth are identified early or receive timely care, due in part to the critical shortage of school behavioral health providers (Cummings et al., 2022). It’s clear that, “students, now more than ever, need SNs to be leaders in the delivery of mental health care in schools” (Kaskoun & McCabe, 2022, p. 36). SN visits for behavioral health concerns have significantly increased compared to prepandemic numbers, particularly for student anxiety (Banzon et al., 2022). The National Association of SNs (NASN), the premier membership association for SNs in the United States, has developed the School Nursing Practice Framework that includes evidence-based standards for school nursing practice (NASN, 2024), and advocates for SNs as essential members of schools’ interdisciplinary behavioral health team since they “provide critical links to prevention, early identification, intervention, and referral for behavioral/mental health concerns” (NASN, 2021). Behavioral health promotion and intervention activities detailed in an early version of NASN’s position statement include SNs involvement in the recognition of early warning signs, development and implementation of health plans, screenings, referrals, basic behavioral healthcare delivery, providing education, and crisis intervention planning (NASN, 2017).
DC has had a long history of delivering an array of school behavioral health services (Acosta Price & Lear, 2008), with city leaders making increasingly significant investments over the last 5 years to develop a comprehensive school behavioral health system (District of Columbia Department of Behavioral Health [DBH], 2017). DC Public Schools and DC public charter schools,2 along with the DC Department of Behavioral Health, DC Department of Health (DC Health), and community partners collaborated to expand behavioral health care across all public schools. To date, the program has placed clinicians from community-based organizations in all of DC’s approximately 250 public schools to offer all students a continuum of school-based behavioral health prevention, early identification, and treatment. The goal of this city-wide initiative is to “provide interventions for all families of students with behavioral health needs; reduce aggressive and impulsive behavior; and promote social and emotional competency in all students” (DBH, 2017).
Implementation of this school behavioral health initiative required coordination between community and school-hired professionals, including SNs. Currently, DC School Health Services Program employs over 170 school health suite staff, including SNs and allied health professionals, who provide school health services to over 80,000 students in DC public schools implemented by Children’s School Services at Children’s National Hospital (DC Health, n.d.). Consistent with national practice frameworks (NASN, 2024), SNs in DC carry out various health promotion and prevention activities unique to a SN’s skillset, such as maintaining individualized health plans (IHPs), delivering care to students with chronic and acute health problems, and making referrals for families to community resources (Bohnenkamp et al., 2015).
Both the published and practice-based evidence about SNs’ involvement in school behavioral health functions give rise to some important considerations. Studies have shown that a significant gap exists between SNs daily responsibilities, the behavioral health activities they are encouraged to engage in, and the preprofessional training they have received (Muggeo & Ginsburg, 2019). For example, SNs have reported little experience in conducting behavioral health screenings and mention a lack of training in behavioral health assessment or access to behavioral health screening tools as significant obstacles (Stephan & Connors, 2013). Professional development (PD) efforts to address these training needs often focus on specific subject matters rather than common practice elements or they do not provide implementation support to help SNs apply what they have learned (Bohnenkamp et al., 2015). Despite their expertise and unique access to students, families and other pediatric providers, nurses working in school settings regularly report being excluded from interprofessional collaboration with members of the school’s behavioral health team (Dale et al., 2021; Granrud et al., 2019).
The purpose of this study is to clarify the daily behavioral health activities urban SNs perform, what they believe to be part of their responsibility, how prepared they feel to perform these functions, and what barriers prevent their involvement that would allow healthcare administrators, supervisors, and nursing educators to address gaps in practice for nurses working in PK3-12 schools. The current study aims to answer the following questions:
What is SNs’ perceived role in the provision of school behavioral health in DC schools?
To what extent do SNs feel equipped with the skills and support to fulfill their role in school behavioral health service provision?
What types of behavioral health training content is of interest to DC SNs?
The university-affiliated authors partnered with leaders from DC Health’s Community Health Administration in Spring 2020 to explore the current activities, perception of role, and training needs of SNs working in schools across DC. Surveys were distributed by email to approximately 170 health suite staff members practicing in DC public schools serving students in PK3 through grade 12 from mid-March through April 2020. After conveying consent to participate in the study, respondents completed a series of closed- and open-ended questions and submitted their survey responses anonymously. Due to the differences in roles and responsibilities related to student behavioral health, nurse managers and Unlicensed Assistive Personnel (designated as health technicians in the DC School Health Services Program), were excluded from the sample.
A 24-item survey questionnaire was adapted from two main sources: the NASN quick poll questions used in the Bohnenkamp et al. (2015) study and the Boston Children’s Hospital survey used for the Training and Access Project (Kaye et al., 2022). The survey included questions to understand the extent to which SNs feel knowledgeable and confident in their ability to perform a variety of behavioral health functions, barriers they experience related to screening, as well as their level of interest in various youth behavioral health-related training content. The survey collected information on participant demographics, such as gender, race and ethnicity, years working as a SN, their grade level placement, and prior behavioral health training received. Next, SNs were asked two open-ended questions, “What does ‘student behavioral health’ mean to you in your role as a school nurse?” and “What specific responsibilities do school nurses have in supporting student behavioral health?.”
The four questions from the Boston Children’s Hospital survey measuring SNs ability and confidence to address student behavioral health needs were rated on a 5-point Likert scale, from “not at all true” to “very true.” The psychometric properties of the full Boston Children’s Hospital survey are reported in the study by Kaye et al. (2022), but the four items in the current study yielded an average interitem covariance of .6603 and scale reliability coefficient of .9085, for the 134 responses provided by the SNs who answered. A question about desired training topics listed eight content areas from the Boston Children’s Hospital Survey (Kaye et al., 2022).
The list of behavioral health practices, screening tools, and obstacles to conducting behavioral health screening were from the Bohnenkamp et al. (2015) study. Questions were: “I currently engage in the following mental health practices in my school(s),” “I currently routinely use a screening tool to screen students for the following mental health concerns,” and “What are the biggest obstacles to conducting mental health screenings in your school(s)?,” each listing multiple choice responses from which to choose. Final survey questions, “How likely are you to be included in school-based discussions or meetings related to behavioral health issues?” and “How often do school leaders or school mental health professionals share information or data about mental health prevention, early identification, and treatment services with you?” were rated on a 5-point scale (“very unlikely” to “very likely” and “never” to “always,” respectively).
Quantitative data were analyzed using Stata version 17.0. Frequencies were run on demographic variables and current behavioral health activities, and descriptive analyses calculated self-reported level of knowledge and ability to address student behavioral health needs. Chi-square analyses examined the relationships between categorical variables of interest.
For the two open-ended survey items, three researchers (JG, RS, and BS) employed a priori coding, informed by the survey items and their original sources. Responses were coded and documented in Microsoft Excel. The question “What does ‘student behavioral health’ mean to you in your role as a school nurse?” was coded using the SAMHSA definition of behavioral health (SAMHSA, 2017). Responses to the question “What specific responsibilities do school nurses have in supporting student behavioral health?” were coded for alignment with the NASN (2017) position statement that outlined specific responsibilities of the SN (NASN, 2017).
A total of 154 SNs working in DC public schools completed the survey, constituting a 91% response rate. Of those who responded, most SNs in DC identified as non-Hispanic Black (N = 109, 70.8%), female (N = 140, 90.9%), were in the SN profession for either 0 to 5 years (N = 62, 40.3%) or more than 10 years (N = 58, 37.7%), and worked in elementary schools in school year 2019–2020 (N = 126, 81.8%). Eighty-four percent (84.4%, N = 130) of respondents participated in PD related to behavioral health as part of their employment, 54.6% (N = 84) had brief exposure to behavioral health training some time during their formal nursing education, and only 11.7% (N = 18) indicated they had prior specialized training in psychiatric nursing (Table 1).
Overall, 93.5% (N = 144) of SNs said that they engage in a combination of behavioral health practices in their schools, which should be understood in light of this sample’s tendency to work with younger students. The top behavioral health activities that SNs implemented included referring students to school behavioral health professionals (N = 106, 68.3%), administering (N = 104, 67.5%) or monitoring (N = 93, 60.4%) psychotropic medications, and communicating with parents/guardians about student behavioral health concerns (N = 101, 65.6%). Less frequent activities included providing extended counseling to students (three or more sessions; N = 5, 3.3%) and conducting behavioral health screening or assessment (N = 15,9.7%), with 6.5% of SNs (N = 10) indicating they did not engage in any behavioral health practices in their schools. The open-ended “other” responses indicated SNs support multiple members of the school community; such as, assisting in “briefing the staff before a student with some special needs starts coming to school, teaching the (classroom) aides who do one-on-one care about expected behaviors and outcome of their various students,” and holding “IHP sessions with parents and students” to manage students’ medical conditions. Most SNs reported not using a formal screening or assessment tool to identify students with behavioral health concerns (N = 124, 89.2%). Among those used, the most common screeners were for attention-deficit/hyperactivity disorder, behavioral issues, and suicidal ideation (Table 2).
When asked about their involvement in student support meetings, 46.1% (N = 71) of SNs said they were “likely” or “very likely” to be included in school-based discussions or meetings related to behavioral health issues, while 22.1% (N = 34) said they were “unlikely” or “very unlikely” to be included. Additionally, 24% (N = 37) of SNs said information or data about behavioral health prevention, early identification, and treatment services was “often” or “always” shared with them, 33.1% (N = 51) said this information was “sometimes” shared, and 32.5% (N = 50) reported school leaders or school behavioral health professionals “rarely” or “never” shared this type of information. In response to an open-ended question about additional comments, some SNs described their intentional or inadvertent exclusion from key health discussions: “School staff … including mental health staff … do not like to share any information with the school nurse,” “I only know about mental health issues when the students happen to come to me,” or “from the UHC (universal health certificate) or medication plan.” Another argued “Principals need to realize, appreciate and utilize the nurse input as an integral part of the team and create opportunities to invite us in. The culture of exclusion should be abated.”
One hundred and thirty-six SNs wrote a relevant response to the following open-ended question, “What does ‘student behavioral health’ mean to you in your role as a school nurse?” and were coded as “behavioral/emotional wellbeing” (a description or identification of a student’s maladjustment) or “actions that affect wellness” (an understanding of the context and conditions that facilitate or hinder a student’s maladjustment). The majority of responses (N = 93) indicated SNs believe behavioral health is associated with a student’s demonstrated ability to function in their everyday lives. This includes whether the student exhibits challenging behaviors or specific psychiatric conditions or symptoms, such as depression or anxiety, or more general descriptions such as students “acting out” or engaged in “behavior that is not managed well or displaced.” One SN summarized it as “(behavioral health) can mean anything from their ability to learn in the classroom to psychiatric issues diagnosed by a physician.”
Although fewer (N = 52), respondents also mentioned that behavioral health constitutes the understanding of the conditions of students’ lives that influence their individual level of functioning. Some respondents emphasized the need for “understanding the cause/reason why the children are suffering with behavior issues…,” while another listed the types of stressors that could impact student well-being, such as “the effects of homelessness, drugs, mental illness, anxiety, hunger, incarcerated parent(s), trauma….” Other SNs shared that behavioral health includes the promotion of strong coping skills and strategies to withstand adverse social or physical factors and the need to advocate for healthy living and learning conditions. One SN described the interconnection between the environment and a student’s emotional state: “Student behavioral health is the portrayal of thoughts, attitudes, and beliefs of a student as it relates to the physical, emotional, mental, spiritual, and social wellbeing in their environments.”
In response to the open-ended question, “What specific responsibilities do school nurses have in supporting student behavioral health?,” 138 respondents shared their perspective about the SN professional role. These responses were coded against six categories in the NASN 2017 position statement: recognizing warning signs; adhering to confidentiality; developing and monitoring health plans, such as individualized education plans and IHPs; screening or providing behavioral health education to students; engaging in care coordination and referrals to school providers or community resources; and delivering behavioral health educational programming to adults who support youth behavioral health. In addition to these six, three additional categories emerged, including medication management, counseling or direct services to students, and advocacy. About one-third (N = 90, 30.9%) of responses stated care coordination and referrals of students and families to the school’s behavioral health team or to community resources as essential SN responsibilities. One-fifth (N = 61, 20.9%) of the responses conveyed the importance of identifying students in need and recognizing early warning signs that may indicate an underlying behavioral health condition. Approximately 17% (N = 49) of the responses mentioned involvement in counseling or direct support to students followed by 12.7% (N = 37) acknowledging the role of the SN in managing student medication (Table 3).
Several comments about SN responsibilities illustrate the value of SNs to help create a safe and trusting environment that facilitates students’ disclosure that can lead to appropriate referrals to other available providers. One SN highlighted their role as a member of the school’s interdisciplinary team: “I make sure that the students feel comfortable with disclosing information with me. Then I can find someone who can better assist with meeting their needs.” Respondents noted they also provide emotional support directly to students, offering an accessible space for students to talk about issues and receive education about effective ways to manage emotions: “Nurses can provide a safe space for students to decompress, provide a listening ear, provide students with support and teach positive constructive ways to cope and express their emotions….” This support, along with being an advocate within the school community, extends to parents as well, as SNs reported they educate parents about their child’s behavioral health challenges and provide appropriate resources to address them: “The school nurse acts as a liaison between the family, school and medical staff by helping to identify the needs of the students and support them in whatever (is) necessary.”
A number of respondents focused on their unique qualifications to monitor the intake and side effects of psychotropic medications, but also felt it was the SN’s general responsibility to support students’ health holistically: “Aside from giving medication as needed, nurses also have the responsibility to educate students on how to keep and remain healthy, not only physically but mentally and socially.” Another stated their overall responsibility to engage in the array of supports that make up a comprehensive school behavioral health approach: “(SN) play an active role in mental wellness promotion, mental health screening and early intervention programs and to assist in managing the ongoing treatment of mental health in the school setting.”
Few DC SNs (N = 15) indicated they conduct behavioral health screening. The top three barriers to performing behavioral health screening were the lack of tools and resources (N = 74, 48.1%), obtaining parental consent and student assent (N = 40, 25.9%), and the lack of training (N = 56, 36.4%), as exemplified by one comment; “most of us fly by the seat of our pants on this issue but have been given little to no formal training.” In response to “other” barriers to their involvement in screening, respondents noted the school’s behavioral health team professionals are qualified and available to conduct these assessments, as well as mixed message they receive around the SNs scope of service. One respondent stated they were not told that screening for behavioral health concerns was part of their responsibility, while another mentioned their school explicitly told them that it was not the role of the SN to screen students. In addition, respondents mentioned lack of time as a significant barrier to conducting screenings given they oversee many routine health suite visits and attend to students with complex physical health needs.
Chi-square tests of independence were performed to examine the relationship between level of behavioral health training and years in the profession. SNs practicing for more than 5 and less than 10 years, as well as those practicing for less than 5 years, had significantly more exposure to behavioral health training during their nursing education compared to SNs practicing for over 10 years, X2 (2, 151) = 6.33, p = .04. There was no significant association between the number of years SNs were in practice and having had psychiatric training, X2 (2, 151) = 1.13, p = .57, or receiving behavioral health PD as part of their employment, X2 (2, 151) = 1.39, p = .49.
A high number of SNs in the study reported it was moderately/very true that they could identify (N = 108, 77.7%) and/or address (N = 98, 72.6%) behavioral health issues exhibited among students, as well as know how to manage student behavioral health crises (N = 88, 63.8%). Yet, selfreported competence varied by years in the profession, with SNs who had practiced for less than 10 years reporting greater confidence in their ability to address student behavioral health issues compared to SNs who had been practicing for over 10 years, X2 (8, 138) = 15.66, p < .05).
SNs with prior psychiatric nursing training were more likely to report greater competence to perform certain behavioral health functions for students with difficulties than those who did not have that specialized training. There were significant associations between having psychiatric nurse training and reporting a greater ability to address student behavioral health issues, X2 (3, 135) = 11.39, p = .01, and confidence, X2 (4, 138) = 16.07, p = .003, and knowing how to manage student behavioral health crises, X2 (4, 138) = 12.69, p = .01. Yet, there was no significant relationship between prior psychiatric nursing training and being able to identify student behavioral health issues, X2 (3, 139) = 2.01, p = .57. Neither having brief behavioral health exposure during nursing education nor engagement in behavioral health PD activities were associated with an SN’s ability to identify, address, or manage student behavioral health needs. Furthermore, the association between ability to perform various behavioral health functions and grade level placement was only significant among SNs working in middle schools, who reported being better able to address behavioral health issues compared to SNs who were not placed in middle schools, X2 (3, 135) = 8.0; p = .05 (Table 4).
The majority of DC SNs were interested in more training for every one of the behavioral health topics listed in the survey, with over 50% reporting they were “very interested” in each topic. Across all respondents, the training topic of greatest interest was “Stress Management and Self-care for the SN” (N = 105, 75%). Other highly desired topics were, “Understanding Trauma and its Impact on Learning” (N = 102, 73%), “Crisis Intervention” strategies (N = 93, 67%), and “Building Effective Teams” (N = 89, 64%). In response to “other” topics SNs wanted, some stated condition-specific training on substance use, autism spectrum disorder, and oppositional defiant disorder, while others suggested broader topics, such as the impact of social media on youth and how to establish a culture of social, emotional, and behavioral health in the school.
Some differences were noted on the behavioral health training content most desired by SNs when comparing several work-related characteristics (Table 5). SNs in the profession for less than 10 years (“0to5”and “more than 5 but less than 10”) expressed greater interest in additional training on “Behavioral Health Symptoms and Systems” compared to SNs who had been practicing 10 or more years, X2 (8, 137) = 15.59; p = .05. A similar difference emerged between SNs in the profession fewer than 10 years reporting greater interest in “Understanding Trauma and its Impact on Learning,” X2 (6, 139) = 14.57; p = .02, compared to those in the profession 10 years or more, but no other significant differences emerged on SN interest in behavioral health training topics by number of years in the profession.
Analyses indicated there was an association between grade level placement and the degree to which SNs indicated interest in various behavioral health training content. SNs working in DC preschools and/or elementary schools were significantly more interested to learn about “Stress Management and Self-care for the SN” than if they did not work with those grade levels, X2 (4, 140) = 15.15; p < .01, and X2 (4, 140) = 16.51; p < .01, respectively. In addition, SNs working with preschoolers were also more interested in training on “Strategies for Supporting Students’ Social, Emotional, and Behavioral Health” than those working with older students, X2 (4, 138) = 9.75; p = .05. Being placed in a high school was also significantly associated with SNs interest in learning about “Crisis Intervention,” X2 (4, 138) = 10.72; p = .030 (Table 5).
This study explored DC SNs current activities, perceived role in school behavioral health service delivery, and the extent to which they felt equipped to fulfill these functions. Consistent with findings from other studies (Banzon et al., 2022; Kaskoun & McCabe, 2022; McIntosh et al., 2022), this study found that DC SNs consider themselves trusted, front-line providers with whom students feel comfortable talking about challenges and stresses and are, therefore, an important point of entry into behavioral health care. This is particularly true for the identification of behavioral health disorders and referral to therapeutic services in or outside of the school. Despite the majority of SNs having prior experience with youth behavioral health and feeling a sense of responsibility to provide needed care, many SNs reported a general lack of preparation, training, and/or confidence in their ability to assess or help treat student behavioral health problems, consistent with prior studies (Stephan & Connors, 2013). Barriers prohibiting their active involvement in behavioral health activities included a lack of assessment/screening tools, poor clarity around roles and scope of service, and limited training on specific behavioral health issues and approaches, as reflected in other reviews (Ravenna & Cleaver, 2016).
Results also highlight that ability and confidence to perform some behavioral health functions differed by years in the field and level of prior behavioral health exposure/training. Understandably, nurses who had psychiatric specialization training expressed greater confidence in addressing behavioral health issues and student crises than those without that prior training. Among those expressing less confidence, SNs who graduated from nursing school 10 or more years ago reported feeling less confident conducting behavioral health activities than their less experienced counterparts. Ironically, more veteran nurses also reported significantly less interest in training on certain topics than SNs who graduated more recently. Reasons for this difference are not clear, yet it is possible that veteran nurses may be more likely to feel student behavioral health is not a core component of their practice or, alternatively, that newer concepts in school health (such as “trauma in schools”) are less familiar to experienced SNs who were not introduced to these terms in their nursing preparation programs.
Care coordination and referral to school or community behavioral health providers was a common practice reported by DC SNs, yet almost half of SNs said they were involved in school-level team meetings (and one-fifth of respondents said they rarely or never were) and roughly one-third of SNs said school leaders or behavioral health providers rarely or never shared behavioral health resources with them. It appears that DC SNs may be more likely to be invited to meetings about student-level needs but are less likely to know or be involved in discussions about schoolwide programs or resources making up the school’s intervention continuum.
All training content areas were highly endorsed, yet DC SNs indicated that stress management and self-care was their top training priority, consistent with more current studies that have examined the behavioral health toll for SNs of working in stressful conditions (Merkle et al., 2023; Moyes et al., 2024). Interest in training content varied by grade level placement, with SNs working in DC preschools and/or elementary schools reporting a significantly greater interest in learning about stress management and self-care and were also more interested in receiving training in strategies for supporting students’ social, emotional, and behavioral health than those working with older students, suggesting a targeted approach to help SNs engaged in preschool nursing is warranted (Lynn, 2020). SNs desire for strategies to support students’ social, emotional, and behavioral health aligns with the urgency felt to provide positive early experiences for this age group given the influence of environment on brain architecture and the child’s lifelong learning, behavior, and overall health (Shonkoff, 2010).
This study informs local decisions about ways to strengthen SN competencies in DC, yet implications for the broader national and international school health and school nursing fields are evident. Recommendations around training delivery, school-based collaboration, and professional role delineation are offered below. The demands for student behavioral health support commonly outweigh available school and community resources. This alarming fact underscores the need for all school professionals, including SNs, to hone critical identification, assessment, and engagement skills in order to effectively participate in the delivery of prevention, early intervention, and brief treatment services in schools.
This study highlighted the need for expanded education and training on integrated behavioral health content and developmentally appropriate, school-based strategies as part of traditional SN preparation programs. SN educators and school health administrators can explore specialized training curricula designed to build SN capacity, such as the Mental Health Training Intervention for Health Providers in Schools, an in-service SN training program to help manage student behavioral health needs that includes information on assessment tools used in schools (Bohnenkamp et al., 2019; Weaver et al., 2019) or Child Anxiety Learning Modules, a six-session SN-delivered cognitive behavioral therapy intervention for children with anxiety (Drake et al., 2015). Consistent with the School Nursing Practice Framework (NASN, 2024), PD for SNs should also include tools and guidance on identifying modifiable social and environmental stressors that may worsen student health and strategies for mitigating their impact (Center for Health and Health Care in Schools, School-Based Health Alliance, National Center for School Mental Health, 2023). To improve behavioral health literacy, reduce stigma around help-seeking, and increase behavioral health referrals, evidence-based training like Youth Mental Health First Aid can complement the access, relationships, and trust SNs often engender throughout their school community (Haggerty et al., 2019). Furthermore, offering competency-based behavioral health continuing education, which combines new knowledge with other competencies such as communication skills, program planning, and coordination of care, can strengthen important transferable skills and maximize SNs impact on a variety of health conditions that influence learning, development, and well-being (Shattuck et al., 2024).
Results from this study suggest that the delivery and content of training may need to be differentiated to meet the varied needs of SNs. PD and behavioral health curricula for SNs could be tailored to address knowledge or skill deficiencies, especially for veteran SNs who may be more likely to lack exposure to current trends on youth behavioral health or feel less confident performing behavioral health practices in present-day school contexts. The costs and benefits of delivering training and practice sessions in role-alike spaces (e.g., where only nurses learn together) or interdisciplinary spaces (e.g., DC School Behavioral Health Community of Practice where interdisciplinary providers jointly learn and improve their professional practice) need to be piloted and assessed. Even when training gaps are addressed, challenges exist regarding meaningful opportunities for SNs to collaborate with other school staff on student behavioral health issues.
The clear delineation of roles, particularly in the delivery of a broad array of behavioral health support, could improve communication, collaboration, and accountability for SNs. As an expanded role for SNs is considered, concerns around increased reporting demands arise, yet some approaches like task shifting (i.e., assigning nonclinical tasks [paperwork] to support staff) show promise in maximizing the time and expertise of those with specialized behavioral health skills to address the rising behavioral health demand (Zabek et al., 2022).
Increasing the opportunities for interprofessional education and multidisciplinary teaming approaches would not only benefit students, but support collaboration and cross-fertilization of learning among SNs, teachers, and other school health and behavioral health professionals (Bohnenkamp et al., 2015; Pestaner et al., 2021). Noteably, education leaders are key to ensuring the involvement of SNs on the school behavioral health team. SNs seek better preparation to address student behavioral health, and may benefit from PD focused on how to effectively advocate for themselves and their students, but they also want supervisors and administrators to facilitate their integration into school behavioral health team meetings, planning efforts, and initiatives. Because SNs are often unable to leave the health suite unattended for extended periods of time, their participation on these teams may require accommodations and flexibility.
The DC Health School Health Services Program has made considerable efforts to implement recommendations from this study. To decrease fragmentation and avoid duplication of behavioral health services in schools, DC Health established a process flow for SNs to better define the SN’s role in DC’s school behavioral health system. Guidance such as this has helped streamline school referral processes and strengthen care coordination protocols, while also preventing behavioral health team members from working in silos or maintaining discrete channels of communication. In addition, DC Health expanded their internal staff to include a dedicated behavioral health training coordinator and behavioral health professionals. These staff conduct site visits to assess SN’s knowledge of behavioral health services and to review their skills, familiarity, and comfortability with screening and referring students for behavioral health care. These visits not only reinforce the SNs role in the behavioral health process but also bolster and encourage onsite collaboration between the SN and the school’s behavioral health team.
Importantly, this study was conducted in Spring 2020, at the start of the COVID-19 pandemic when school closures were occurring in DC, nationally and globally. The level of uncertainty and stress experienced at that time could have influenced how DC SNs answered the survey questions. A major limitation of this study is the potential for response bias given findings were based on self-report data from SNs only and collected at a single point in time. In order to ease administration the researchers identified questions used in prior studies or sections of established surveys, yet this could have reduced their validity and reliability scores. In addition, revised or adapted questions would have helped differentiate between SNs or to test the impact of certain contextual variables. For example, when asked the number of schools an SN traveled to each week, the categories were not segmented enough to generate meaningful data for analysis as over 95% of respondents selected the “1to5” category. There was also a lack of delineation between whether a respondent had previous nursing experience before becoming an SN, which could have illuminated differences in training needs for SNs new to the nursing profession compared to those new to school nursing more specifically. The use of focus groups would have yielded more in-depth qualitative data than the open-ended survey items and offered insight into the relationships between SNs and their school behavioral health team, or highlighted bright spots where SNs felt well-integrated and utilized as part of their student support team.
The current study examined the activities, perceptions, competencies, and training needs of 154 SNs in DC to better understand their involvement in school behavioral health programs and services. DC SNs report they participate in a variety of behavioral health activities, such as identification and referral, but feel particularly underequipped to play a more prominent role in the screening/assessment and treatment of student behavioral health concerns given insufficient training and education. SNs are interested in training about a variety of behavioral health topics but highlight challenges to their integration as part of a collaborative team. Strategies to address widespread pediatric provider shortages must prepare and utilize SNs as valuable members of a school’s behavioral health team and involve them in deliberations about programs, services, and partnerships needed to improve the well-being of the entire school community. Through consistent collaborative efforts among local health and education partners in DC, the capacity of SNs to effectively support students behavioral health and wellbeing will continue to improve.
The authors thank the participating school nurses and Children’s School Services Program for their collaboration and coordination of school nurse participation. They also thank Michael W. Long for his guidance in earlier drafts of this manuscript. Thank you to Francina Boykin, Erica Collins, and Clarence Miller from DC Health for their assistance and review.
Olga Acosta Price: Conceptualization; Formal analysis; Methodology; Supervision; Validation; Writing – original draft; Writing – review & editing.
Breahnna Saunders: Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Visualization; Writing – original draft.
Julie Gibbons: Formal analysis; Methodology; Validation; Writing – original draft; Writing – review & editing.
Rachel Sadlon: Conceptualization; Formal analysis; Methodology; Supervision; Writing – original draft; Writing – review & editing.
Lori Garibay: Conceptualization; Data curation; Project administration; Validation; Writing – review & editing.
Kafui Doe: Conceptualization; Data curation; Project administration; Validation; Writing – review & editing.
Felicity Nelson: Data curation; Methodology; Project administration; Resources; Writing – review & editing.
Tiffany Wise: Conceptualization; Data curation; Project administration; Resources; Writing – review & editing.
Eartha Isaac: Investigation; Project administration; Resources; Writing – review & editing.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Olga Acosta Price https://orcid.org/0000-0002-2748-6528
“Behavioral health,” as opposed to “mental health,” is used throughout the article to refer to psychological, emotional, and behavioral functioning as well as substance use/misuse.
Washington, DC has both public schools and public charter schools, the latter of which operate as their own local education agencies and represent a diverse group of independent schools. Because all are publicly funded, authors will use the term “public schools” moving forward without differentiating between DC public and DC public charter schools.
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Dr Olga Acosta Price has a PhD in clinical psychology. She is an associate professor in the Milken Institute School of Public Health and Director of the Center for Health and Health Care in Schools at the George Washington University with research expertise in school mental health, school-family-community partnerships, and social influencers of health and education.
Breahnna Saunders, MPH, is a graduate of the Department of Prevention and Community Health at the Milken Institute School of Public Health at the George Washington University. She currently works as a mixed methods researcher at Marketing for Change Co., where she uses qualitative and quantitative methods to inform and evaluate public health behavior change programs.
Julie Gibbons, MSN, MPH, has served as a school nurse for five years and is a doctoral student in the School of Nursing at the George Washington University studying school nurse workplace factors and psychological well-being.
Rachel Sadlon, MPH, was associate director of the Center for Health and Health Care in Schools at the George Washington University with expertise in school mental health. She is currently the Director of the Healthy Schools & Wellness Programs in the Office of the State Superintendent of Education in DC.
Lori Garibay, MPH, MA, was Program Manager for Data Quality Assurance and Improvement, Child, and is currently Division Chief, Child, Adolescent, and School Health Division, Family Health Bureau in the DC Department of Health. Her expertise is in school health, data analytics, and public health program evaluation.
Kafui Doe, EdD, MPH, CHES, PMP, CPH was formerly the Chief of the Child, Adolescent and School Health Division and is currently the Family Health Bureau Chief and the District of Columbia’s Title V Maternal and Child Health Services State Director at DC Department of Health. Her expertise includes but are not limited to community health, school health, strategic planning, and change management.
Felicity Nelson, MPH, was formerly a Public Health Analyst in the Child, Adolescent and School Health Division of the Family Health Bureau in the DC Department of Health and is currently a research associate at FHI 360 to help advance equity, health and well-being through data-driven, locally led solutions globally.
Tiffany Wise, MPH, was the Special Projects Coordinator in the Child, Adolescent, and School Health Division and is now serving as the Maternal, Infant, Early Childhood Home Visiting (MIECHV) Program Coordinator in the DC Department of Health Family Health Bureau. Her expertise and work stem from her background in maternal and child health.
Eartha Isaac, BA, is a Public Health Advisor in the Family Health Bureau of the Community Health Administration in the DC Department of Health with a background in school health, legislative affairs, and privacy policy.
1 Center for Health and Health Care in Schools, Milken Institute School of Public Health, the George Washington University, Washington, DC, USA
2 School of Nursing, the George Washington University, Washington, DC, USA
3 District of Columbia Department of Health, Washington, DC, USA
Corresponding Author: Olga Acosta Price, Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, 950 New Hampshire Avenue, NW, Suite 300, Washington, DC 20052, USA. Email: oaprice@gwu.edu
